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Low health literacy among Black and Hispanic (racial minority) women in the United States might have contributed to the increased incidence rates of cervical cancer in this population. Persistent infection of the Human papillomavirus (HPV) accounts for over 90% of cervical and anal cancers; 70% of the oropharynx, vaginal, and vulva cancers; and 60% of penile cancers (Centers for Disease Control and Prevention [CDC], 2016a). Between 2008 and 2012, HPV-associated cervical cancer incidence rates among Blacks, Hispanics, and Whites were 9.2, 9.7, and 7.1 per 100,000, respectively (Viens et al., 2016); and the incidence rates are 41% and 44% higher among Black and Hispanic women, respectively, with White women as referent (American Cancer Society [ACS], 2015; ACS, 2016a). From 2009 to 2013, the age-adjusted cervical cancer mortality rates among Black, Hispanic, and White women were 3.9, 2.6, and 2.1 per 100,000, respectively (U. S. Cancer Statistics Working Group, 2016). The United States Food and Drug Administration approved the first HPV vaccine for women aged 12 to 26 in 2006 to help address the increasing trend (CDC, 2016b). Unfortunately, black women are 30% less likely to initiate the vaccine uptake, and Hispanic women are 62% less likely to complete the required vaccine series (Daniel-Ulloa, Gilbert, & Parker, 2016).

A literature review shows that previous research on HPV vaccine uptake disparity is mainly focused on socioeconomic factors (Giorgi Rossi, Baldacchini, & Ronco, 2014; Perkins, Brogly, Adams, & Freund, 2012); individual beliefs or experiences with vaccines (Baker et al., 2012; Cates, Brewer, Fazekas, Mitchell, & Smith, 2009); and cultural factors that are coupled with lack of awareness ( Blackman et al., 2013; Daley et al., 2010; Notaro, 2012). Each of these studies focused on single-factor determinant, and so far the individually focused factors have not been able to close the disparity gap. Currently, only 24.4%, 25.0%, and 34.0% of Black, Hispanic, and White women, respectively, initiate the first HPV vaccine dose. Such rates are much lower than the Healthy People 2020 vaccine goal of 80% (ACS, 2016b; Daniel-Ulloa et al., 2016; Elam-Evans et al., 2014). Unfortunately, there is little to no research study available on how low health literacy (which encompasses intention to vaccination and motivation to perform a behavior) affects the HPV vaccine uptake among the marginalized women. Veldwijk et al. (2015) recommend measurement of health literacy level when studying vaccination decision behavior. The disparity in HPV vaccine uptake may be due to low health literacy levels in the marginalized communities since 24% and 41% of Black and Hispanic adults, respectively, have below basic health literacy level skills; and only 2% and 4% of Black and Hispanic adults, respectively, are proficient in health literacy (Kutner, Greenberg, Jin, & Paulsen, 2003). Understanding the effect of low health literacy at the individual or community level on HPV vaccine uptake may provide the potential strategies to increase the vaccine uptake and reverse the high incidence rates of cervical cancers among the minority women in low socioeconomic communities.

The purpose of this dissertation is to assess the relationship between health literacy and HPV vaccine uptake among young adult Black and Hispanic women between 18 and 26 years, living in the United States. The Integrated Behavioral Model (IBM) will be the theoretical framework for this dissertation. Health literacy level is the degree to which an individual acquires or accesses health information, processes, and makes the health-related decision for themselves or a family member—and will be the independent variable in this dissertation. According to Nutbeam (2000), health literacy level may be classified functional, interactive, or critical—referring to a person’s ability to transmit factual health information on health risks, create opportunities to develop skills to interact and influence social norms, and act on socioeconomic determinants of health, respectively. HPV vaccine initiation, on the other hand, will be the outcome variable. Socioeconomic status (income and education attainment), and age will be among the potential confounding variables. Attitude towards HPV vaccine, perceived norm, and personal agency are other variables that will be examined. My dissertation research questions will aim to examine the relation between the health literacy and HPV vaccine uptake to strengthen the knowledge base, promote, and influence social change in vaccine uptake planning; and possibly generate new ideas (Newman, Ridenour, Newman, & DeMarco Jnr., 2003).

Question 1: Does health literacy level relate to the HPV vaccine uptake among marginalized adolescent and young adult women aged between 18 and 26 years living in the United States, controlling for the effects of income, educational level, and age?

Question 2: Does ethnic background relate to the HPV vaccine uptake among marginalized adolescents and young adult women aged between 18 and 26 years living in the United States, controlling for the effects of income, educational level, and age?

The integration of the seven constructs agreed upon by the prominent behavioral theorists (including Albert Bandura, Martin Fishbein, Marshall Becker, and Harry Triandis) in the early 1990s into the Fishbein’s 1967 Theory of Reasoned Action (TRA) and Ajzen’s 1991 Theory of Planned Behavior (TPB) is known as the Integrated Behavioral Model; and that will provide the theoretical framework for this dissertation (Branscum & Bhochhibhoya, 2016; Glanz, Rimer, & Viswanath, 2008). The Integrated Behavioral Model (IBM) is an emerging health behavior theory which combines elements from the four most popular behavioral change theories—Social Cognitive Theory, Transtheoretical Model, Information-Motivation-Behavioral Skills Model, and the Theory of Planned Behavior which collectively can provide guidance to public interventions (Michie, West, Campbell, Brown, & Gainforth, 2014). The IBM can be deductively used to assess factors that may affect an individual’s ability to acquire, process, and act on health-related information. This theory posits that behavioral intention is antecedent to behavior, and the intention to perform a behavior is usually influenced by the independent interactions of a person’s experimental and instrumental attitude, perceived control and self-efficacy, and injunctive and descriptive norms (Ajzen, 1991; Glanz et al., 2008). Madden, Ellen, and Ajzen (1992) demonstrate that a person’s behavior is always preceded by behavioral intention and the intention is influenced by a person’s subjective norms as well as their attitude toward the behavior. Thus, favorableness or unfavorableness attitude toward the behavior, perceived normative expectations, and perceived self-efficacy determine the intention to perform a behavior (Glanz et al., 2008). Besides the intention to perform a behavior, the IBM identifies other immediate factors that influence behavior to include knowledge and skill to perform the behavior; absence of environmental constraints; salience of the behavior; and existing habits of performing the behavior (Glanz et al., 2008; Olin et al., 2010). Demographic characteristics, attitudes towards targets, personality traits, and individual differences are among the background factors of the indirect variables that may play significant roles in influencing a behavior (Michie et al., 2014). According to Fishbein and Ajzen (2011), the Integrated Behavioral Theory is a value-expectancy model—identifying the cognitive pathways of factors that precede and influence an individual’s intention to behavior.

This is a quantitative research method that will examine the relationships between the variables, using a secondary data set that is collected on the general population. The dependent research variable in this study is dichotomous (HPV vaccine initiation—yes/no) and the independent variables (health literacy level and ethnicity) will be categorical. Secondary data set from the 2015 National Health Interview Survey (NHIS) will help identify socio-demographic information on people that have received at least one dose of the HPV vaccine and their population-level health literacy levels will be derived from the individuals’ sociodemographic characteristics such as age, gender, highest education attainment, income level, marital status, and employment. Factors that include cancer prevention knowledge, attitude, accessibility and utilization of health care services, and environmental barriers will be assessed as well to identify variables that help minority women to act upon their health intentions. The dataset is likely to include socioeconomic status, ethnicity, and environmental barriers.

Health literacy is defined as “the degree to which an individual can obtain, communicate, process, and understand health information and services in order to make appropriate health decisions” (Somers, Mahadevan, Somers, & Mahadevan, 2010, p. 7). Nutbeam (2000) describes the three levels of health literacy—functional, interactive, and critical health literacy. Critical health literacy transcends above functional and interactive health literacy levels; and it comprises of both personal and community responsibilities that apply individual cognitive skills and societal empowerment to determine the degree to act on health information (Guzys, Kenny, Dickson-Swift, & Threlkeld, 2015; Nutbeam, 2000).

Racial minority young adult women in this dissertation will be women between ages 18 and 26 years who identify themselves with either Hispanic or African American heritage. For the purpose of this study, African American (Blacks) will include women of the African American racial/ethnic background as well as immigrants of the same age group from Africa, the Caribbean islands, and English-speaking countries in South and Central America. Similarly, Hispanics will be defined as women who identify themselves as Hispanic in the survey as Hispanics and it includes immigrants from South and Central America. Immigrants from Spain living in the United States will not be among considered Hispanics.

HPV vaccine uptake will be defined as any acceptance of the vaccine dose (≥1 dose) and does not matter whether the individual completed all the three doses or not.

As of 2016, the United States population comprised of 76.9% Whites, 17.8% Hispanics or Latinos, and 13.3% Blacks or African American (U.S. Census Bureau, 2016). By 2050, the African American and Hispanic population is expected to be 13.0% and 29.9% of the total population (Rodriguez et al., 2014). Despite the growth in the minority population, 24% and 41% of the African American and Hispanic population, respectively, in the United States have below the basic health literacy level (Kutner et al., 2003) and the low socioeconomic status of racial/ethnic minorities is associated with the low health literacy levels (Rikard, Thompson, McKinney, & Beauchamp, 2016). Current HPV vaccination strategies that focus on the individual factors without considering the societal component have not been adequate. Understanding the relationship between health literacy level and HPV vaccine uptake will improve the vaccination coverage; and prevent cervical cancer incidence and deaths among the minority women.

Quinn, Jamison, Musa, Hilyard, and Freimuth (2016) posited that complacency, convenience, and confidence contribute to influenza vaccine hesitancy among African Americans. In this dissertation, there is an assumption that there is no difference between the racial/ethnic minority women and their white counterparts, in terms of convenience to HPV vaccine information. Without this assumption, then any difference in the vaccination rates between the two groups may be explained by the convenience the vaccine (Saslow et al., 2012). Another assumption in this study is that any vaccine hesitancy behavior is not influenced by any factor outside the individual’s sociodemographic characteristics. Thus, participants in the study do not have any bad experiences with the healthcare services and there is no underlying medical condition to prevent them from the HPV vaccine (CDC, 2017b; Dubé et al., 2013).

This study will focus on non-institutionalized civilian racial minority women (African American and Hispanics), between 18 and 26 years, living in the United States. This population is at risk because majority of them are sexually active and yet face challenges in their ability to acquire and act on health information. The young adult women are expected to be able to navigate the complex healthcare system for reproductive health information, evaluate the information, and act on it.

The HPV vaccine is approved for females between 9 and 26 years, however, health literacy is measured on adults only. Health decisions for children and adolescents below 18 years are controlled by parents so the health literacy level of adolescents (16 to 17 years) will not depict any relationship that may exist with HPV vaccine uptake.

Women over 26 years of age are not the focus of this study because the clinical trial of the HPV vaccine did not show any benefit for women over 26 years of age (CDC, 2017). The study does not include the HPV vaccination rate of men. Cervical cancer is caused by persistent infection of the virulent strains, types 16 and 18. Female vaccination against the virus will prevent such persistent infection of the cervix. Institutionalized minority women and those in the military are excluded due to accessibility issues and ethical concerns.

This study will not be able to establish the validity of participants’ responses to survey questionnaire which may introduce misinformation bias or misclassification. Crucial information such as risky sexual behavior and other activities that were not collected during participants’ interview will place a limitation to the analysis and interpretation of the result. Lack of triangulation of participants’ responses may introduce self-reporting bias and social desirability bias. Missing data on key valuable variables may impact the sample size. The findings may not be generalized to other countries outside the United States.

Depending on the amount of missing data, cases with missing data on key variables needed to determine the health literacy level or information on HPV vaccine uptake will be deleted, listwise. In case more than 30% of the data is missing, then the amount of complete data will be compared to the power analysis to ensure that the available data has minimum of 80% power to detect existing relationship between the independent and dependent variables.

The FDA licensed the HPV vaccine in 2006, yet the average national vaccine uptake rate in 2013 was 57.3%, lower than the 80% target rate set by the Healthy People 2020 (Elam-Evans et al., 2014). A 2013 National Health Interview Survey that included 6,444 participants between the ages of 18 and 30 years reported that 34.0%, 24.4%, and 25.0% of white, black, and Hispanic women, respectively, initiated the first HPV vaccine dose (Daniel-Ulloa et al., 2016). Among those who start the first dose, more than three-quarters of the White women completed the recommended three doses, compared to 42.8% completion rate among the Black women (Daniel-Ulloa et al., 2016). Unfortunately, the recommended strategies to overcome the HPV vaccination barriers approved on June 9, 2015, by the National Vaccine Advisory Committee (NVAC) do not identify health literacy as an obstacle to the vaccine uptake. The NVAC recommendation is contrary to the suggestion to consider health literacy in vaccination promotion (NVAC, 2015; Veldwijk et al., 2015). This public health problem can be articulated within a conceptual framework so that the findings will become part of the building blocks in the public health discipline. Thus, this dissertation will add to the body of science by examining the relationship between health literacy and HPV vaccine uptake in the identified population to possibly offer a better recommendation to help reduce the prevalence of HPV-related cancers.

Economic resources are limited and are under considerable budgetary restraints. Instead of spending over $8.0 billion (2010 U. S. dollars) on direct medical cost in screening and treating cervical cancers, an understanding of the relationship between the population’s health literacy level and HPV vaccine uptake will influence public health intervention strategies. Thus, prevention efforts through vaccination will cost between $390 and $450 per vaccine series per person to prevent the onset of cancer (Association of Reproductive Health Professionals, n. d.).

This dissertation will add to the body of knowledge in Public Health regarding the antecedents and consequences of health literacy about HPV vaccine uptake among the underserved young adult women, aged 18 to 26 years, in the United States. The study will also provide public health practitioners with the information that will help to accurately understand factors that influence the individual’s behavioral intention toward the HPV vaccine uptake as well as factors within the complex health care system that hinder this population’s health literacy as they begin their adulthood lifestyles. Thus, this dissertation may guide public health practitioners to influence policymakers to address environmental barriers and current healthcare policies to afford the young adult women levels of privacy and confidentiality—when covered by parents’ health care insurance.

Cervical cancer incidence and deaths is prevalent in the racial/ethnic minority (African American and Hispanic) women. Persistent infection of the high risk strains of the human papillomavirus (types 16 and 18) account for over 70% of cervical cancer, yet, the protective HPV vaccine coverage among this population is far below the expected vaccination goal as set by Healthy People 2020 (Bakir & Skarzynski, 2015; Lin et al., 2015; Yoo et al., 2017). Most of the existing literature focuses on single variables to help explain the vaccine coverage disparity. Unfortunately, there is limited literature on the relationship between health literacy and HPV vaccine uptake among racial/ethnic minority women. The current guidelines NVAC guidelines to improve HPV vaccine uptake does not identify low health literacy among the minority population as a barrier.

Using the Integrated Behavioral Model, the purpose of this dissertation is to quantitatively analyze secondary data from the 2015 NHIS to assess whether there is a significance relationship between health literacy level and HPV vaccine uptake among the target population. Knowledge gained from this dissertation will contribute to the body of knowledge to guide health promotion programs.

The literature review chapter will focus on mostly peer-reviewed published articles that have addressed the major variables of this dissertation (race/ethnicity, health literacy and its determinants, and HPV vaccine uptake); and the relationships of the variables to one another. The majority of the literature discussed in this section represents current articles published in English since 2011. The articles reviewed in this section were identified using PubMed, EBSCO, SAGE, and ScienceDirect. Keywords used for the search include HPV vaccine, ethnic minority, college women, young adult women, health literacy, health knowledge, HPV vaccine awareness, cervical cancer prevention, and normative influences.

Health professionals usually assume that individuals between 18 and 26 years possess the basic health skills needed to obtain health-related information to make a health decision either for themselves or family members. However, the complex interaction between the individual factors (literacy skills, health knowledge, sociocultural, and past experiences) and the established health care system (healthcare practitioners, healthcare infrastructure, and quality of the healthcare workforce) that work together to influence a person’s health literacy level is seldomly explored. The individual determinants of health literacy directly influence the capacity at which a person uses and acts on health information (Sørensen, Van Den Broucke, Fullam, Doyle, & Pelikan, 2012). Factors that determine an individual’s health literacy level is not limited to basic literacy. Instead, the complex interactions and communications between an individual and the current health care infrastructure, together with the available social capital affect the degree at which a person can acquire and apply health information (McCray, 2005). For instance, cultural and linguistic skills of an individual and that of the professional providers, including the use of scientific vocabularies, and epidemiologic jargons contribute to health literacy level of a person (Singleton & Krause, 2009; Sun et al., 2013). Sociodemographic characteristics such as gender, race/ethnicity, marital status, age, education, and income are identified as the basic determinants of health literacy (Martin et al., 2009; Sun et al., 2013). Research studies that focus on individual factors such as HPV and HPV vaccine knowledge, awareness, attitudes, beliefs, and access to healthcare have not fully explained the low HPV vaccine uptake among the African American and Hispanic women.

The 2007 Paasche-Orlow and Wolf conceptual model of explaining the relationship between low health literacy and health outcomes posits that health care access and utilization, individual self-care, and the complex interaction between patients and providers could significantly impact the health outcome (Sun et al., 2013). Young adult women who not too long ago were in their adolescents are now expected to have the ability to access general health information and make significant decision on clinical issues; and also acquire the skill set needed to access risk factor information for disease prevention (Sørensen et al., 2012). There are many variables that influence an individual’s ability to adopt a healthy behavior. According to the Integrated Behavioral Model, factors such as normative and subjective beliefs, attitudes towards a behavior, perceived control and self-efficacy, knowledge about the replacement behavior, and environmental conditions contribute to an individual’s intention and ability to perform the desired behavior (Glanz et al., 2008).

A cross-sectional study by Ratanasiripong, Cheng, and Enriquez (2013) conclude that young college women would accept mandated HPV vaccine for people between the ages of 18 and 26 years. Researchers in this study applied the Ajzen’s Theory of Planned Behavior (TPB) to identify variables that influence the young college women’s decision process of accepting the HPV vaccine. The TPB is an extension of the constructs in Theory of Reasoned Action (attitude and subjective norms), and TPB includes perceived control to address situations where the individual may not have a complete volitional control (Glanz et al., 2008). With a convenience sampling design, the researchers recruited 384 (175 unvaccinated and 209 vaccinated) college women, ages 18 to 26 years old, from a public university in southern California. Targeted students who received an email from researchers and consented to participate in the study were directed to a website to complete a self-administered questionnaire. The survey measured participants’ attitudes, subjective norms, perceived controls, intention to receive the vaccine (among those unvaccinated), and knowledge about the HPV and HPV vaccine (Ratanasiripong et al., 2013). The Cronbach’s coefficient alpha of each of the instruments ranged from 0.70 (perceived control) to 0.96 (intention to vaccinate), and a 5-point Likert scale was used to measure all responses. A t-test for continuous variables and Fisher’s exact tests for categorical data show no significant differences between the vaccinated and unvaccinated participants regarding religion, health insurance status, class major (college courses), Pap test status, sexually transmitted infection, and relationship status (Ratanasiripong et al., 2013). However, a chi-square test reveals a significant difference between the vaccinated and unvaccinated groups, regarding race—10.4%, 24.3%, and 28.2% of the vaccinated respondents were Black, Latino, and Caucasian, respectively (Ratanasiripong et al., 2013). After controlling for the significant covariates (age, ethnicity, and age at first sexual intercourse) in a hierarchical multivariate logistic regression, subjective norms (providers’ recommendations, support from mothers and peers), attitudes about receiving the vaccine, and perceived control consistently predict the intention to receive the vaccine. Despite the self-report of multiple sexual partners, some of the non-vaccinees did not perceive their risk of acquiring the virus: indicating that low knowledge about the virus could impact the behavioral beliefs (Ratanasiripong et al., 2013). This study is only limited to one university in California and nonstudents were excluded so the findings cannot be generalized to all young adult women. The participants’ positive subjective norms coupled with the positive attitude toward the vaccine mandate can be explored by public health practitioners to increase the vaccine uptake. Future studies should focus on identifying factors such as environmental constraints, habits, and salience of the behavior that can facilitate the intention to behavior.

In an exploratory factor analysis from a longitudinal study design, Dempsey, Fuhrel-forbis, and Konrath (2014) used the Carolina HPV Immunization Attitude Scale (CHIAS) to measure college-aged women’s attitudes toward the HPV vaccine. CHIAS is a validated instrument that measures the individual’s attitudes toward the HPV vaccine among parents with an adolescent child—looking at access, perceived harm, vaccine effectiveness, and uncertainty. The authors recruited 139 unvaccinated college-aged participants and administered all the 16-item CHIAS questions that had been modified to reflect the current population. The investigators performed the data analysis using linear and logistic regressions to assess the associations between the factor structures and HPV vaccination; and logistic regression for the relationship between the factor structures and HPV vaccine uptake. The analysis reveals that the HPV vaccination attitudes regarding perceived harm is similar among young college-aged women (18 to 26 years) and parents of adolescent children. Thus, perceived harm about the HPV vaccine strongly predicts the vaccine intention and uptake among the two different populations (parents with adolescent children and college-aged women). This study shows the need to address the concern of perceived harm in any public health intervention effort and conduct additional studies to identify other predictor variables. Although this study identifies a key predictor of young women’s attitude to HPV vaccine, it does not address other factors such as socioeconomic and environmental factors that affect people’s degree of accepting the vaccine. Secondly, the participants in the study are students so there may be a selection bias as those not in colleges are not represented.

A cross-sectional study involving 571 unvaccinated young adult women, between the ages of 18 and 26 years old, measured the subjective normative influence of mothers and health care providers on the participants’ intention to receive the HPV vaccine (Head & Harsin, 2016). All recruited participants in this study were from a large Midwestern university; and they comprised of 82.8%, 9.5%, and 3.0% Caucasians, African Americans, and Hispanics, respectively (Head & Harsin, 2016). The researchers assessed participants’ vaccination intention by asking questions about past HPV vaccine conversations with their mothers and doctors. Past maternal and physicians’ recommendations were categorized into three groups: vaccinate, do not vaccinate, and no conversation. The researchers measured the participants’ HPV vaccine intention on a 4-point Likert-type scale ranging from “very unlikely” to “very likely” and treated it as the outcome variable; and the past recommendations as the predictor variables (Head & Harsin, 2016). An ANOVA test shows that past positive recommendations from mothers and physicians lead to stronger intention to vaccinate. The ANOVA result demonstrated that the young women who did not receive any recommendation from their mothers or physicians about HPV vaccination were more likely to receive the vaccine than their counterparts told not to do so (Head & Harsin, 2016). A multiple regression model that entered participants’ intent to vaccinate as the outcome variable shows that past mothers’ recommendation about the vaccine was the most significant predictor of the dependent variable. The findings from this study indicate that subjective normative influence from health care providers and mothers significantly impact young women’s intentions to vaccinate against HPV (Head & Harsin, 2016). This study has a theoretical framework which ensures the validity and reliability of the findings to give the assurance needed to guide health education programs. However, the participants are predominantly Caucasian college students in only one university in Midwest—it does not fully represent the tapestry of the America population. The Theory of Reasoned Action (TRA) in this srudy reveals certain factors that are antecedent to the intention. However, the TRA does not address knowledge, skills, experience, and environmental constraints that may affect a person’s ability to act on the intention (Glanz et al., 2008). Subjective normative factors are shown to influence the intention to vaccinate against the HPV, so future studies should build on this idea by identifying factors that may facilitate and convert the intention to the desirable behavior outcome.

Another study that conveniently sampled college women, 18 to 26 years of age, was conducted by Ziemer and Hoffman (2013) who used the Health Belief Model (HBM) as the conceptual framework to examine attitudes towards the HPV vaccine. The authors recruited 208 students and sought to identify predictor variables to the HPV vaccine intention. The young women in this study, mean age of 21.1 years, were recruited in 2010 from five different United States’ tertiary institutions in the West, Mid-West, and Mid-Atlantic to the West regions. The participants were mostly Caucasians, only 8.7% and 4.3% were African Americans and Hispanics, respectively (Ziemer & Hoffman, 2013). The investigators used survey questionnaire, measured on a Likert scale, to assess consented participants’ attitudes towards and intention to receive the HPV vaccine. Participants’ HPV vaccination status and intentions to receive the vaccine were the outcome variables. The independent variables included the six constructs of the HBM (perceived susceptibility and severity, perceived barriers and benefits, self-efficacy, and cues to action); HPV knowledge; sexual risk factors; and subjective norms (Ziemer & Hoffman, 2013). A hierarchical regression model showed that three predictor variables—social environment, self-efficacy, and perception of the vaccine significantly predict the women’s intention to vaccinate (Ziemer & Hoffman, 2013). The authors suggest that positive external factors (subjective norms) promote encouragement to the young adult women, increase their knowledge about the vaccine, minimize barriers, and improve the chances of vaccine uptake. Although this study applies a theoretical framework to study women’s attitude to the HPV vaccine, the exclusion of non-college students does introduce blank elements into the study. Ziemer and Hoffman (2013) recommended future studies to explore both social and informational environmental factors to increase the vaccine uptake.

Instead of recruiting from college campuses only, Casey, Crosby, Vanderpool, Dignan, and Bates (2013) recruited 495 unvaccinated young adult women, 18 to 26 years old, in five primary women health clinics and four community college sites in southeastern Kentucky counties. Between March 2008 and September 2009, the researchers recruited and provided a self-administered questionnaire to consented young women to assess the normative influences (parents, friends, and healthcare providers) of the college students. In anticipation of low functional health literacy among the women recruited from the health clinics, the same questionnaires were administered to the respondents in an interview-assisted format (Casey et al., 2013b). The authors reported 98% participation rate in this longitudinal study—248 and 247 of the participants were recruited from the community college and the clinics, respectively. Upon completion of the survey, the researchers issued to each participant a free voucher for all the three HPV vaccine required doses (Casey et al., 2013b). Each coupon had a code to match with the participant’s questionnaire. The outcome variable of the study is the use of the voucher for the first vaccine dose within two months of completing the survey (Casey et al., 2013b). The predictor variables, on the other hand, include the possibility of multiple sexual partners; sexual behavior within the past twelve months; a Pap test; an abnormal Pap test result; a close family member with cervical cancer; and hormonal contraceptive usage (Casey et al., 2013b).The researchers dichotomized the predictor variables into “favorable” and “less favorable” and performed a bivariate analysis to determine relationships between the variables. A multivariate two-block hierarchical logistic regression with all predictor variables that had achieved alpha-values of less than 0.10 in the bivariate analysis identified the associations among the variables. The descriptive analysis shows no significant differences regarding age, sexual behaviors, and clinical history between those recruited from clinics and the college students (Casey et al., 2013b). The logistic regression reveals that those with favorable normative support—peer support, paternal encouragement, and healthcare providers’ recommendation positively predict the outcome variable; and those recruited from the primary health clinics were 60% more likely to initiate the vaccine uptake than the college students (Casey et al., 2013b). The authors recommend further exploration of father-daughter relationship to help improve the vaccine intake among this population. The strength of this study includes the use of both college-enrolled students and those outside the education system. Secondly, it is among the few studies that did explore women-paternal endorsement. The data used in this study, however, was collected almost ten years ago so the associations between the variables might have changed. Even though the researchers provided vouchers for free vaccination, the study did not assess the degree of at which the recipients’ interactive and critical health literacy levels could impact their ability to act on the voucher, as explained by the Nutbeam (2000) health literacy model.

In an anonymous web-based survey, Marchand, Glenn, and Bastani (2012) used the Health Behavioral Framework as a theoretical framework and skip logic to administer survey questionnaires to 178 young adult community college students, 18 to 26 years old, in Los Angeles. The recruited participants were 32% and 59% African American and Hispanics, respectively. This study was aimed at assessing whether social norms and health care (healthcare provider recommendation) variables are associated with HPV vaccine initiation (Marchand et al., 2012). Although 79% of the participants reported knowledge about HPV, 30% had not heard or did not know about the HPV vaccine (Marchand et al., 2012). Bivariate comparisons using chi-square and t-test analyses show that health care providers’ recommendation, perceived safety concern of the vaccine, health care utilization, and social approval are all significant predictors of HPV vaccine uptake. A multivariate logistic regression identifies younger age, and health-related majors in school as significant predictors HPV vaccine uptake among college students (Marchand et al., 2012). Other key predictors of HPV vaccine uptake include doctors’ recommendation. However, recruitment was limited only to college students, and the findings cannot be generalized.

With a purposive sampling method, Yi et al. (2013) recruited 95 Vietnamese American women, mean age 48.9 (±7.3) years, from a large Vietnamese shopping center in Houston to assess and describe the women’s HPV knowledge and HPV vaccination intention for their daughters. All the participants in the study were born in the Vietnam, had lived in the United States for an average of 18.2 years, and each had a daughter between the age of 9 and 26 years. The researchers conducted face-to-face interviews in either English or Vietnamese, depending on the participant’s language preference (Yi, Lackey, Zahn, Castaneda, & Hwang, 2013b). Two trained bicultural and bilingual female staff conducted the interviews, and the translated questionnaires were reviewed by the native Vietnamese speaking staff among the research team. The translated questionnaires were tested and approved by a group of experts in the Vietnamese community. Of the 95 participants, 28% reported proficiency in English speaking; 29% in reading; 22% in writing; and 32% reported of understanding the spoken English very well. The data analysis revealed that only 45% of the respondents reported adequate knowledge of the virus. The researchers used a backward elimination multiple logic regression to enter the possible predictors into a model to determine the probability of participants’ HPV knowledge to predict their awareness of the vaccine. A multivariate logistic regression result identifies English proficiency (speaking, understanding, and writing), higher education, health insurance, and affordability of the HPV vaccine are significant predictors of HPV awareness (Yi et al., 2013b). Among those with inadequate knowledge of the virus, 86% reported their intention to vaccinate their children, upon recommendation by their healthcare providers. The lack of strong validity and reliability of the measuring instruments of the translated survey instrument and the lack of theoretical framework affect the generalizability of the results. Nevertheless, results of this study show that functional health literacy among parents can have a huge impact on young adult women as some of them may depend on their parental recommendation for the vaccine. Head and Harsin (2016) reported that the vaccine recommendation by mothers is a strong subjective normative predictor for vaccine intent among young adult women. The findings from this study demonstrate that young women whose mothers have limited education, no health insurance, and not proficient in English may not have any recommendation for the vaccine.

Massad et al. (2015) assessed young women adults’ knowledge on HPV, cervical cancer prevention, and HPV vaccination.In this multicenter prospective cohort longitudinal study involving 974 mostly low-income minority women at six consortia—Bronx, Brooklyn, Chicago, Los Angeles, San Francisco, and Washington, D. C.; the researchers applied 44-item self-administered questionnaires to gather data on the variables of interest in 2007, 2008 to 2009, and 2011. A paired t-test analysis of the data shows a significant increase in overall knowledge of HPV and HPV vaccine, between 2007 and 2011. The mean knowledge score for 2007, 2008-2009, and 2011of 12.8, 13.9, and 14.9, respectively. Despite the significant increase in knowledge among the participants, the authors admit substantial gaps in the understanding of the link between HPV and cervical cancer prevention (Massad et al., 2015). This study also confirms Strohl et al. (2015) findings that income and education level are among the factors that affect HPV, cervical cancer, and HPV vaccine knowledge (Massad et al., 2015). Massad et al. (2015) therefore recommend further studies to understand better the determinants behaviors associated with HPV prevention and cervical cancer detection.

Between November 2007 and January 2009, Patel et al. (2009) recruited 256 unvaccinated young college women, 18 to 26 years, from a gynecological health care clinic at the University of Michigan to examine two key variables: intent to receive HPV vaccine and effect of an educational intervention. Over 67% of the consented students were Caucasians, and they were randomized into either the intervention or controlled group, using pre-assigned computer generated numbers. The investigators employed the Theory of Planned Behavioral (TPB) and used a single question to assess participants’ vaccination intent, within six months of the enrollment date. Of the 256 respondents, 84.4% were single; 70.7% undergraduates; and 48.9% reported of between 2 and 5-lifetime sexual partners (Patel et al., 2009). The researchers dichotomized the outcome variable (intention to vaccinate) and used logistic regression to analyze the data. The 41% of participants who intended to receive the vaccine cited concern of cervical cancer, HPV, and physicians’ recommendation as the reasons to vaccinate. Thus, perceived susceptibility and subjective norms (parents, physicians, and religious bodies) significantly predict intention to vaccinate. Concerned for vaccine safety, high vaccine cost, side effects, and uncertainty were among the reasons that influenced other students not to vaccinate. Individuals with the intention to vaccinate (at the baseline) were10 times more likely to receive the vaccine within six months (Patel et al., 2009). The findings confirm the TPB assumption that intention is antecedent to a behavior and identify variables that can influence intention to vaccinate. This study, however, did not include sufficient amount of minority women, 9.0% and 4.7% African American and Hispanic women, respectively, to adequately assess the marginalized population’s vaccine intent and uptake. The small sample size of participants who received the vaccine does not allow the investigators to evaluate factors that motivate individuals to move beyond their intentions.

In a sequential explanatory mixed method design, Luque, Castañeda, Tyson, Vargas, and Meade (2012) used the social marketing conceptual framework to conduct a formative study to identify environmental factors that influence HPV vaccine uptake among low-income Latina farmworkers in central Florida. The researchers used purposive sampling design to recruit 40 patients, 18 to 55 years old, with no history of cervical cancer from two health care clinics. Trained and qualified interviewers used a structured interview protocol in administering the structured questionnaire to the 40 participants to gather the quantitative data for the study. The study also included six additional other participants (five Mexicans and one Guatemalan) recruited as key informants who provided information regarding perceived barriers and benefits, as part of the qualitative aspect of the study (Luque et al., 2012). A trained bilingual interviewer interviewed the key informants (community leaders and health care providers) in a room adjacent to the clinic. Two independent reviewers, using thematic analysis approach with an interrater reliability coefficient of 0.80 analyzed the qualitative data and then grouped the responses by perceived barriers and benefits, promotions, place, and cost (Luque et al., 2012). In addition to low HPV and HPV vaccine knowledge and awareness, the factors that influence vaccine uptake include access to health care, lack of health insurance, inadequate information and recommendation from the healthcare providers, language barriers, the concern of promiscuity, misconception about the vaccine, and transportation to the site of the vaccine. The preventive benefits from the vaccine, potential to save numerous lives, and the people desire to stay in good health were among the perceived benefits (Luque et al., 2012). The limitations of this study include the smaller sample size and also narrowly focusing on only Latinas from Mexico and Honduras. The study, however, identifies certain structural barriers and perceived benefits that help to understand the population’s reason of not accepting the vaccine. The findings, therefore provide the platform that future studies can build on to increase the HPV vaccine among Latinas.

In another mixed method design, Joseph et al., (2012) used the Health Belief Model constructs, and the grounded theory to identify factors that could facilitate or hinder HPV vaccine acceptability among low–income minority young adult women, 18 to 22 years old with the mean age of 19 years. The researchers recruited 132 participants from an urban academic medical center and two community health centers. Consented participants were mostly Latinas and Haitian immigrants and spoke at least one of the following languages: English, Spanish, or Haitian Creole. Recruitment for this longitudinal study occurred in the pediatric and adolescent departments of the identified sites, between July 2007 and January 2009. Through interviews, the investigators assessed participants’ HPV and HPV vaccine knowledge, the level of trust in the healthcare providers, and vaccination intention—measured on a four-point Likert scale. The qualitative portion of the measurement, on the other hand, involves the application of four constructs of the HBM (perceived severity, perceived susceptibility, perceived benefits, and perceived barriers) in semi-structured interviews. The authors aimed at understanding the respondents’ perceptions (attitudes and beliefs) that may hinder acceptance of the HPV vaccine. The researchers reviewed the medical records of each participant at twelve months and five years from study enrollment to assess the relationship between intention to vaccinate and actual vaccination (Joseph et al., 2012). The continuous and categorical data from the quantitative measurement were analyzed using t-tests and chi-square tests, respectively. Four investigators reviewed the responses from the qualitative questionnaire; coded them into themes; and examined their relationships with vaccination intention, race/ethnicity, and HPV vaccine uptake (Joseph et al., 2014). The quantitative results reveal that 94% of the participants trusted the physicians’ recommendations for the vaccine. All the Caucasians in the study reported knowledge of HPV infection, compared to 87% and 85% of the African Americans and Latinas, respectively (Joseph et al., 2014). Marital status and trust in physicians’ recommendation significantly predict the intent and receipt of the vaccine, respectively. The qualitative study show that inadequate knowledge about the virus and the vaccine, fear of promiscuity, perceived low risk, and cost of the vaccine contribute to low vaccination uptake. The benefits of the vaccine include the life-saving potential of the vaccine and physicians’ recommendations. Nearly 90% of the respondents expressed a positive attitude toward HPV vaccination, before sexual debut; and the majority of them supported the idea of mandating the vaccine. The Latinas reported limited parent-daughter and physician-patient discussions of sexuality, as compared to the Caucasian and black women. The findings of this study show a disconnect between vaccine intention and vaccine initiation—out of the 90% respondents who reported intent to vaccinate, only 51% initiated the vaccine; and 78% of those who initiated completed the three doses, over five years (Joseph et al., 2012). This study identifies barrier and perceived benefits of the vaccine and also highlights on the disconnect between vaccine intent and initiation. The selection criteria of age-limit excluded those between the ages of 23 and 26 years who may have a different perception of the vaccine’s barriers and benefits. The review of the medical records serves as a triangulation method to reduce reporting bias; however, this study could have been impacted by selection bias as only those that visited the clinics between July 2007 and January 2009 were eligible to be in the study. The use of the Integrated Behavioral Model could help identify the factors that can motivate individuals to act on their intentions.

In a cross-sectional study involving 1467 African American adults from Houston metropolitan area, Hoover et al. (2015) examined secondary data from a longitudinal cohort study (Project CHURCH) to assess the association between health literacy and indicators of poor physical or mental health. The conveniently sampled participants comprised of 74.6% females and 25.4% males, with a mean age of 45.19 years (ranging from 18 to 86 years); 35% reported annual household incomes of less than $50,000; and approximately 49% of those enrolled in the study had at least a college degree. The investigators used a single item-questionnaire comparable to the Rapid Estimate Adults Literacy in Medicine (REALM) and Short Test of Functional Health Literacy in Adults (STOFHLA) to assess participants’ level of health literacy. Of the 1467 participants, nearly 19% demonstrated low health literacy (Hoover et al., 2015b). A multiple logistic regression analysis of the data reveals a significant association between low health literacy and the following variables: smoking, poor physical health, and mental health. Low health literacy independently predicts perceived stress and depressive symptoms, and it is a significant predictor of poor health among African American adults. The study demonstrates how low health literacy elucidates multiple health risks factors. Thus, the 24% and 41% of the African American and Hispanic population, respectively, with low health literacy are at risk for risky health behaviors (Hoover et al., 2015; Kutner et al., 2006). The study, however, only looks at functional health literacy without considering other factors that can motivate an individual to perform a behavior, after the intention.

In a correlational cross-sectional study Cha et al. (2014) used convenience sampling method to recruit 106 mostly African Americans who were overweight or obese young adults, 18 to 29 years with a mean age of 23.99 years, from the Atlanta metropolitan area. The researchers did not include any respondent with confirmed diagnosis of diabetes, as well as those with diseases that could influence A1C test. Qualified and consented individuals who provided information on all the variables of interest comprised of 81women and 22 men; 82.5% had at least some college education; and 22.3%, 31.1%, and 46.6% were overweight, moderately obese, and morbidly obese, respectively (Cha et al., 2014b).The authors used aspects of the transtheoretical model to examine the relations among health literacy, self-efficacy, and dietary quality. The participants’ health literacy of food labels was assessed using the Newest Vital sign Scale (numeracy, basic literacy, and document literacy); and categorize the results into low, medium, and high. The path analysis shows that Blacks in the sample significantly had low health literacy, less basic education, and had higher BMI. The analysis further shows that low health literacy individuals are less likely to use food labels, compared to those with high health literacy group; low health literacy significantly associates with low dietary quality; and self-efficacy and low health literacy positively predict food label use behavior and dietary quality (Cha et al., 2014b). The authors recommend future studies to identify ways to increase health literacy to improve health behaviors. The findings of this study demonstrate the clear relationship between low health literacy and poor health behaviors among young adults. Nevertheless, the result cannot be generalized due to the small sample size, the convenience sampling design, and the smaller geographical locale.

A study involving 396 college students, 18 to 43 years, at a large Midwest university to assess the relationship between eHealth literacy and factors that influence intention to accept HPV vaccination. The authors found a positive association between the independent variables (attitude, subjective norms, and perceived behavioral control) and HPV vaccine intention (Britt, Collins, Wilson, Linnemeier, & Englebert, 2015a). The participants were predominantly Caucasians (82.8%), and the group’s mean age was 20.3 years old. Of the 396 participants, 219 had not initiated the HPV vaccine, and 149 had received at least one dose of the vaccine. The eHealth literacy was measured using a validated 8-item instrument—eHEALS (Cronbach’s alpha of 0.93), on a 5-point Likert scale. Each of the predictor variables—attitude, subjective norms, and perceived behavioral control, on the other hand, was measured on a 7-point scale with adequate reliability, Cronbach’s alpha ranging from 0.80 to 0.85 (Britt, Collins, Wilson, Linnemeier, & Englebert, 2015b). A correlation analysis showed a positive association between HPV vaccination intention and perceived control with eHealth. A hierarchical multiple regression indicates that perceived behavioral control mediates the relationship between the eHealth literacy and vaccination intent (Britt et al., 2015b). The authors recommend future studies to explore further the influence of eHealth literacy and HPV vaccination belief on the vaccination uptake to help understand and promote healthy preventive behaviors. The findings of this study show that the behavioral intent of the participants is mediated by the three major constructs of the planned behavioral theory—attitude, normative beliefs, and perceived control. However, this study did not include enough African American and Hispanic women, only 3.2% and 3.4%, respectively, in the study so the result cannot be generalized to the marginalized women.

A study to explore the relationship between functional health literacy and cognitive abilities found a strong association between health literacy and cognitive performance among 322 participants with heterogeneous socioeconomic backgrounds in Brazil (Apolinario, Mansur, Carthery-Goulart, Brucki, & Nitrini, 2015a). In a convenient sampling design, the investigators recruited patients 18 years old or older, the mean age of 47.2 years, and average highest educational attainment of 9.6 years from public hospitals in Sao Paulo. The researchers collected consented participants’ demographic information through interviews; and assessed their cognitive performances—global functions, learning, and visuospatial skills using previously validated instruments. Such instruments included the Mini-Mental Status Examination, Brief Cognitive Battery, the Clock Drawing Test, and the S-TOFHLA (Apolinario, Mansur, Carthery-Goulart, Brucki, & Nitrini, 2015b). The descriptive statistics reveal that 90.5% of people with less than four years of formal education have inadequate health literacy; and only 44.5% of the young adults, 18 to 39 years old, demonstrated adequate health literacy (Apolinario et al., 2015b). A binary logistic regression shows a significant association between limited health literacy and poor cognitive performance. This study tests different variables that could influence an individual’s capability of acquiring and processing health information; and the measurement does focus on all three aspects of health literacy—functional, interactive, and critical health literacy. The study, however, could have been impacted by selection bias and the result cannot be generalized. The sample also included older population, some of them might have been suffering from undiagnosed neurodegenerative diseases that could have affected the cognitive results.

A multicenter prospective longitudinal cohort study in Germany with the aim to assess the effect of health literacy on information needs among newly diagnosed breast cancer women tested a hypothesis that patient’s level of health literacy determines their information need (Schmidt et al., 2015). The primary objective of this study was to determine the appropriate health literacy training measures needed to provide information to support newly diagnosed breast cancer patients. The researchers recruited 1359 newly diagnosed patients from 60 hospitals (with 54 breast centers) between February and August 2013. The investigators used a modified 33-item questionnaire from Cancer Patients Information Needs Scale in focus-group interviews to gather data. Participants’ health literacy was calculated with the Measurement of Health Literacy in Europe scale (Schmidt et al., 2015). All the participants were18 years or older; 66% married, 70.2% lived with a partner, 39.3% employed, and 28.3% had a college or vocational diploma. A multivariate logistic regression shows that people with low and intermediate education were 43.4% and 32.1% less likely to request information supplementary naturopathy and physical burden, respectively, as compared to the college graduates. The analysis also reveals an inverse relationship between participants’ health literacy level and their unmet health informational needs (Schmidt et al., 2015). This study focuses on the individual’s ability to access, understand, and utilize health information to determine their health literacy level. Thus, the authors provided an operational definition of health literacy (access, knowledge, and utilization) and its relationship to a person’s decision-making capabilities. Despite the strength, only 0.3% of participants were between the age of 20 and 30 years and the findings cannot be generalized to young adult women. Future studies should, therefore, attempt to use similar operationalized definition of health literacy with a greater focus on young adult women.

A multinational cross-sectional study that recruited 4,999 pregnant women from eighteen countries to explore the influence of health literacy on teratogenic risks perception and beliefs of medication; and the mediation effect that perceived medication risks and beliefs have on health literacy and non-adherence behaviors during pregnancy (Lupattelli, Picinardi, Einarson, & Nordeng, 2014a). Of the 4,999 enrollees, 56% were between 20 and 30 years; 38% were 31 to 40 years old; and the majority were recruited from the Western countries and south America (Lupattelli, Picinardi, Einarson, & Nordeng, 2014b). The authors assessed participants’ health literacy using a set of brief screening questions (SBSQ) and trichotomized the result into low, medium, and high literacy. The original questionnaire was in English and Norwegian and later translated into other languages relevant to the participants. The investigators collected all the needed data through an anonymous internet-based questionnaire between October 2011 and February 2012. A multivariate logistic regression analysis of the data revealed a significant association between low health literacy and the following variables: flu vaccine non-adherence, maternal health behavior, and a higher risk of medications perception. The study shows the need to address health literacy as a major component of health promotion and adherence to healthy behaviors (Lupattelli et al., 2014b).

Before 2009, health literacy levels of individual adults have been assessed using one of the validated instruments such as the Newest Vital Sign (NVS), Rapid Assessment of Adult Literacy in Medicine (REALM), and Test of Functional Health Literacy in Adults (TOFHLA). Each of these instruments depends on a set of questionnaires to accurately assess a person’s health literacy. None of the instruments have the capacity to measure the health literacy level at a community or population level. Secondly, the instruments could not be applied to any existing data to measure the health literacy. This limitation of the existing validated instruments prompted Martin et al., (2009) to apply both linear and logistic regression analyses to the 2003 National Assessment of Adult Literacy (NAAL) data to determine the mean health literacy score and the likelihood of a person having an adequate level of health literacy (above basic proficiency).

The development of predictive health literacy models based on existing data was proposed by Martin et al., (2009). The authors demonstrate how multiple sociodemographic variables that include gender, age, race/ethnicity, income, and education can predict the probability of an individual having adequate health literacy level. These predictive models are the results of analyzing the sociodemographic data on 17,446 adults, 18 years and older, from the 2003 NAAL; and the interpretation of the models are similar to the NAAL. The proposed models allow researchers to use existing administrative or census data to estimate the health literacy at both the individual and community levels.

Although the validated predicted models are quite recent, Rasu, Bawa, Suminski, Snella, and Warady (2015) applied the models on the 2005 to 2008 Medical Expenditure Panel Survey (MEPS) data, a nationally representative sample, to assess the impact of health literacy on health care utilization and expenditure. The MEPS involves data on 22,599 participants, mostly Caucasians, and mean age of 49 (±17.8) years old. The authors conclude that individuals with basic or below basic health literacy have relatively more physician visits and spend more on health care, compared to adults with adequate health literacy (Rasu, Bawa, Suminski, Snella, & Warady, 2015b).

In a separate a separate retrospective cohort study, Bailey et al. (2015) validated the 2009 Martin’s proxy health literacy models against the three most commonly used validated health literacy assessment instruments—Test of Functional Health Literacy in Adults (TOFHLA), Rapid Estimate of Adult Literacy in Medicine (REALM), and Newest Vital Sign (NVS). The investigators estimated the health literacy level of participants using sociodemographic information from an existing dataset, Health Literacy and Cognitive Function among Older Adults (LitCog); and directly assessed their health literacy using the assessment instruments. Upon comparing the health literacy results, the authors concluded that there is a fair agreement between the derived health literacy as calculated from the secondary data and the in-person assessment. The study by Bailey et al., (2015) therefore provides further validity and precision to the predictive health literacy model.

The National Health Interview Survey (NHIS) is a nationally representative survey and does not directly measure the health literacy of an individual. However, the validated predictive models can be applied to the data from the multistage sampling design to estimate the mean health literacy scores and the probability of an individual with a given sociodemographic characteristics of having adequate (intermediate or proficient) level of health literacy.

Using existing datasets from the 2008 to 2012 National Health Interview Survey (NHIS), Schmidt et al. (2015) investigated HPV vaccination interests and non-vaccination reasons among 10,513 young adult women, 18 to 26 years, living in the United States. The composition of the respondents was 60%, 18%, and 15.5% White, Black, and Hispanics, respectively; approximately 24% were without health insurance; 25% were below the federal poverty threshold; and over 40% reported up to high school diploma as their highest educational attainment. Of the 10513 participants, about 23% reported receiving at least one dose of the HPV vaccine. The participants without health insurance, those with no specific place for regular care, and those that had received recommendations for the vaccine had greater odds of expressing HPV vaccine interest and intention. The authors identified lack of vaccine information, inadequate disease knowledge, and concern about vaccine safety as the main reasons for not receiving the vaccine. Approximately 35% of the unvaccinated respondents expressed interest in receiving the vaccine. However, the lack of knowledge and environmental factors such as inaccessibility to the vaccine and spousal objection prevent the young adults from acting on their intentions to perform the healthy behavior (Schmidt et al., 2015).

In a similar study, Price, Tiro, Saraiya, Meissner, and Breen (2011), examine the 2008 NHIS data set to assess HPV vaccine awareness and identify the reasons for not receiving the vaccine. Statistical analysis in this study was on a sample of 1583 young adult women, 18 to 26 years of age. Of the 1583 participants, 24.5% had no health insurance, 14.3% did not see a physician or obstetrician in the past twelve months, 16% reported no receipt of any one of the recommended lifetime vaccines, and 83% did not receive the influenza shot or nasal spray in the past year (Price et al., 2011). Overall, 11.7% of the target population reported receiving at least one dose of the HPV vaccine. A multivariable logistic regression reveals that young adult women without health insurance are 86% less likely to initiate HPV vaccination, compared to people with private health insurance. People without a physician or OB/GYN visit in the past year are 43% less likely to initiate the HPV vaccine. Respondents who reported no receipt of the recommended vaccine had odds ratios of 0.32 (95% confidence interval, 0.13, 0.77) to receive HPV vaccine (Anhang Price, Tiro, Saraiya, Meissner, & Breen, 2011). The researchers also found significant HPV vaccine awareness among respondents with private health insurance and also among those that had to utilize the health care system (provider visits or receipt of at least one of the recommended lifetime vaccines) within the past twelve months. Unvaccinated respondents indicated safety concerns of the vaccine, no recommendation by health care providers, lack of vaccine knowledge and awareness, not sexually active, and expensive cost of the vaccine. Among the unvaccinated respondents who reported unwillingness to pay the $500 full price for the vaccine, 98% expressed the willingness to receive the vaccine, at greatly reduced cost. Although this study provides valuable information for public health practitioners as it looked at the actual vaccine uptake, not intentions, it does not combine the sociodemographic characters on the respondents to assess the effect of health literacy on the vaccine uptake.

In a primary research study, Strohl et al. (2015) used a convenient sampling method to assess the knowledge on HPV, cervical cancer, and HPV vaccination among 215 African American women, 18 to 70 years, in Chicago. In this cross-sectional study, the consented participants were surveyed using a validated self-administered tool, “The Awareness of HPV and Cervical Cancer Questionnaires” that was developed by Ingledue et al. in 2004, to assess the knowledge and beliefs on HPV and cervical cancer (Strohl et al., 2015). Out of the 28 questionnaires to assess knowledge, the researchers categorized the cumulative HPV knowledge score of 18 or greater correct answers as “adequate knowledge” and 73% of the participants failed to demonstrate adequate knowledge of HPV and cervical cancer (Strohl et al., 2015). The authors identified household income and the level of education as among factors that positively associated with HPV knowledge. This study raises a critical issue for the need to improve knowledge on HPV, cervical cancer, and HPV vaccination among adult African American women to improve the HPV vaccine uptake. As Kobetz et al. (2013) demonstrated, knowledge is an important determinant of health behavior. The low knowledge on the virus, cervical cancer, and HPV vaccine among adult Hispanic and African American women will negatively affect their HPV vaccine uptake (Kobetz et al., 2013; Strohl et al., 2015).

The National Cancer Institute’s 2013 Health Information National Trend Survey (HINTS) fourth iteration, the third Cycle collected data on respondents’ knowledge and awareness on HPV. In a cross-sectional study design Blake et al. (2015) used the data from the HINTS 4, Cycle 3 to assess how sociodemographic factors—age, race/ethnicity, socioeconomic status, and geographical areas contribute to the gaps in HPV awareness and knowledge. The statistical analysis of the data involved 3,185 samples, 18 years or older, comprising of approximately equal number of males and females. Of the 3185, 78.3% and 12.9% were White and Black, respectively; 82.1% reside in urban areas, compared 17.9% living in rural areas. 66.8% reported highest educational attainment as up to technical, vocational, or some college degree; and 67% indicated their total annual household income of less than $75,000 (Blake et al., 2015). A multivariate logistic regression that uses listwise deletion for case analysis shows that African Americans and “multi-racial” individuals are 57% and 60%, respectively, less likely than whites to report that HPV is a sexually transmitted disease. Gender, age group, geographical location (rural versus urban), and highest educational level significantly predict HPV as a sexually transmitted disease (Blake et al., 2015). Thus, the female respondents and those between 18 and 34 years were more likely to know about HPV and the HPV vaccine. Regarding HPV and HPV vaccine knowledge, men were 75% less likely than women; respondents with high school diploma were 45% less likely than those with a college degree; and those without access to the internet were 32% less likely to have heard of the vaccine (Blake et al., 2015). Since HPV is transmitted sexually and this result shows that men are significantly less aware of the vaccine for prevention, there is the need to include male participants in any education promotion program. Secondly, the results of this study point out that the disparities of the HPV and HPV vaccine knowledge is closely associated with sociodemographic factors and public health practitioners need to take those factors into account in designing health promotion. This study, however, did not stratify the age group to analyze the data separately for the young adults (18 to 26 years). Not all the people in the 18 to 34 years group qualify for the booster vaccine, and it will be difficult to base a health promotion program on this result to target the young adults when planning a health promotion program for HPV vaccine uptake.

A secondary analysis on Project Re-Engineered Discharge and RED-Lit clinical trial data sets at the Boston Medical Center by Mitchell, Sadikova, Jack, and Paasche-Orlow (2012) reveal that low health literacy significantly predicts hospital re-utilization (re-admission or emergency room visit). The investigators set to examine the relationship between health literacy and the return of patients back to the hospital within a month of discharge. The authors hypothesized that low health literacy is a risk factor to hospital re-utilization and used data on 703 patients, 18 years or older (mean age of 51.23 years), from the control group of the trial. Patients’ health literacy was measured using the validated 66-item instrument, REALM, and their hospital re-utilization was assessed by reviewing the medical records at the Center and that of the neighboring hospitals. Of the 703 control patients, 369 and 78 of the subjects were black and Hispanics, respectively; and 20%, 29%, and 51% had low, marginal, and adequate health literacy, respectively. Those with low health literacy patients were more likely to be black, less educated, and from low socioeconomic backgrounds (Mitchell, Sadikova, Jack, & Paasche-Orlow, 2012b). A multivariate Poisson regression analysis of the adjusted incidence rate ratio shows that patients with low health literacy are 46% more likely to return to hospital within a month of discharge. Also, 71% and 67% of the subjects with low health literacy were more likely to be readmitted to the emergency room and into a hospital within a month, as compared to patients with adequate health literacy (Mitchell et al., 2012b). This study only measured the functional health literacy of the subjects, and also it did not stratify the data by age to identify any modification effect due to age. Despite the limitations, this study demonstrates that low health literacy is associated with sociodemographic factors, and can modulate the effect of physicians’ recommendations to patients.

Investigators using a stratified retrospective cohort case-control study in Israel reported that parents’ higher communicative and critical health literacy significantly attenuate vaccine compliance for their children (Aharon, Nehama, Rishpon, & Baron-Epel, 2017). The researchers recruited 309 parents of children who had not completed at least one of the core vaccination protocols before the age of two and assigned them to the study group. Another 422 parents whose children had completed the core vaccination protocols became the control group. The investigators drew from Paasche-Orlow and Wolf (2007), and Nutbeam (2000) models that assume a direct association between health literacy and vaccination compliance; and mediating effects of knowledge, attitudes, and beliefs as the conceptual framework of their investigation (Amit Aharon, Nehama, Rishpon, & Baron-Epel, 2017). The authors employed the 2008 Ishikawa, Takeuchi, and Yano’s 13-item questionnaire to measure participants’ functional, communication, and critical health literacy levels. Assessment of the subjects’ knowledge, belief, and attitudes, on the other hand, was performed using Salmon et al. (2004) instruments (Amit Aharon et al., 2017). A chi-square, ANOVA, and MANOVA analyses of the collected data show that parents in the control group had significantly lower income and educational levels than those in the study group. The path analysis of the data reveals the inverse relationship between functional health literacy (HL) and pro-vaccine attitude; higher critical HL significantly corresponds to higher anti-vaccine attitude; and communicative HL is directly associated with vaccine completion (Amit Aharon et al., 2017).

Without any specified theoretical framework, Kobetz et al. (2013) used a cross-sectional study of secondary data from the 2007 Health Interview National Trends Survey to examine the knowledge and awareness of 375 Hispanic women regarding HPV vaccine acceptability. The data analysis of this study reveal high HPV awareness among the participants, 18 to 44 years old; and the same population has low knowledge about the HPV infection and cancer (Kobetz et al., 2013). Despite the potential bias introduced by the convenient sampling and the smaller sample size of the study design, the authors conclude that the limited knowledge among the Hispanic women concerning the cervical cancer-causing virus influences their HPV vaccine uptake. The authors of this study recommended the need for public health practitioners to disaggregate and focus on those with limited knowledge because knowledge is an important determinant of health behavior (Kobetz et al., 2013).

There is a significant association between low and marginal health literacy and poor health outcomes. Unfortunately, the focus of most health literacy studies have been on older adults, individuals with less than high school diploma, people with low socioeconomic status, and non-English speakers (Institute of Medicine [IOM], 2004). Those between the ages of 18 and 26 years old are usually considered to be college age, and have the ability to read and write (general literacy) which places them outside the at-risk group (Sørensen et al., 2012). Wallace, Rogers, Roskos, Holiday, and Weiss (2006) posit that the use of income and highest educational attainment as proxies for health literacy overestimate the actual health literacy of the individual. A secondary data analysis of a longitudinal study in the Houston metropolitan area shows that approximately 20% had inadequate health literacy, even though approximately 49% and 62% have some college degree and more than $50,000 household income, respectively, per year (Hoover et al., 2015b). As part of a prospective cohort study in Germany involving 1344 participants, Schmidt et al., (2015) demonstrate that individuals with low or intermediate health literacy are less likely to seek health-related information. Schmidt et al., (2015) conclude that factors that influence an individual’s unmet informational needs include health literacy, sociodemographic characteristics, and employment status. Thus, inadequate health literacy may be a modifiable risk factor for certain unhealthy behaviors (Hoover et al., 2015b; Mitchell et al., 2012b); adequate health literacy has a positive influence on health information sources and health beliefs (Kim, Lim, & Park, 2015a). Social capital (bonding with people who have adequate health literacy or living in communities with high community-level health literacy) can attenuate the effect of low functional health literacy on health behavior. Public health practitioners may, therefore, need to look into ways to improve the social capital among the young adults by moving upstream to look at parent-child relationships which persist and informs health behaviors during young adulthood (Johnson, Giordano, Manning, & Longmore, 2011).

Low knowledge about HPV and HPV vaccine, vaccine safety, concern for promiscuity, vaccine cost, inadequate social normative factors, perceived harm, and environmental barriers are among the reasons for low HPV vaccine uptake (Ratanasiripong et al., 2013; Ziemer & Hoffman, 2013). The increased in HPV knowledge and intention to vaccinate have not resulted in improvement in HPV vaccine uptake (Casey et al., 2013; Spleen, Kluhsman, Clark, Dignan, & Lengerich, 2012). Expanse literature demonstrates the role of normative and subjective norms—recommendation from physicians, maternal recommendation for the vaccine, and father-daughter relationship in improving the HPV vaccine uptake (Bennett, Buchanan, & Adams, 2012; Casey et al., 2013; Head & Harsin, 2016). Unfortunately, racial minorities are less likely to receive physician recommendations for the HPV vaccine (Jeudin, Liveright, Del Carmen, & Perkins, 2014; Ylitalo, Lee, & Mehta, 2013).